Greetings, everyone. I see some familiar faces on the participants list. Great to have all of you with us. We're going to get started. People are still logging in, so we're going to get started probably in about three minutes. So hold tight and we'll be with you. And like I said, we're going to be starting right at seven, so I'll be with you shortly. All right, people are still entering the session and we have a couple announcements, so I'm going to take this time to do that. Let me first welcome all of you, all of our cardiovascular providers, our physicians, advanced practice providers, nurses, and CVT members. Thank you so much for taking time out of your busy Tuesday to be with us. I think we have a very, very informative and extremely applicable session for you tonight. If this is your first time joining us for one of these sessions, these webinars are brought to you by the ACC CV Team Educational Committee. We do these monthly webinars to support the educational objectives for those that are preparing for the CCK exam. If we haven't met before, my name is Christopher Walsh. I'm a physician assistant from the Pima Heart Institute and I volunteer on the CV Team Educational Committee. A little bit of housekeeping before we get started and introduce our guest speaker. If you have questions for Dr. Hoosian, we're going to try to get to as many of those as possible at the end of the session. I'll be monitoring the chat, so please put your question in the chat and like I said, we'll get to as many as we can as time permits. Also, if you have any questions about the CV Team Educational Committee, if there's any CV Team members out there that would like to participate, or if you have a suggestion or you would like to see a certain topic presented in this format, I'll put my contact information in the chat after the introduction. And then lastly, before we introduce our speaker, one hour of continuing education credit is being awarded for this session. You'll be receiving an email with a link to an assessment after the session is completed, so be checking your email and you'll have three months to complete that assessment so that you can receive your CME credit. I am absolutely thrilled to have Dr. Michael Hoosian with us tonight presenting this topic. Dr. Hoosian received his medical degree from the University of Miami Miller School of Medicine. He completed his internal medicine residency at the University of Miami and Jackson Memorial Hospital. Dr. Hoosian received his postdoctoral fellowship in molecular cardiology at the Miller School of Medicine, followed by fellowships in cardiovascular medicine and cardiac electrophysiology at the Cleveland Clinic in Ohio. He holds a master's degree in biotechnology and bioinformatics from John Hopkins University. He is board certified in internal medicine and cardiovascular disease. He is a practicing electrophysiologist and he is the director of the atrial fibrillation program at the Piedmont Heart Institute in Atlanta, Georgia. Welcome, Dr. Hoosian. Thank you so much for being here and I'm going to let you go ahead and take over. All right. Yeah. No, thank you so much. It's a pleasure to be here with all of you. I hope the presentation is going to be very informative, very useful for you. We do have a fair amount of content to cover, so I'll go ahead and get started. All right, very good. So what we're going to discuss this evening are the most recent age of relation guidelines, which were published last year in 2023, it's going to be an overview. I'm going to try to touch on the most pertinent. Aspects of of the guidelines and specifically focus on what's new and what's changed. So I personally have no relevant financial disclosures pertaining to this talk, and then everybody else that was involved in putting this together. Also, no, no relevant financial relationships or disclosures. So just a little bit of history here. So the last comprehensive AFib guidelines were released back in 2014. We then had a focus update in 2019. As you can imagine, there have been a lot of changes, both in terms of the technology that we use to diagnose and treat atrial fibrillation, and also in our understanding of atrial fibrillation since 2014. So it's, it's been almost 10 years since we've gotten more contemporary guidelines. And for those of us in the field, and especially those of us that treat a lot of atrial fibrillation, I think we were very grateful that the Heart Rhythm Society and the ACC finally got together and gave us some more contemporary guidelines. So a few points that I want to make before we get into the guidelines themselves. I've tried to make a distinction between more specific practice guidelines versus things that are going to seem a little bit more commonsensical to all of you. I would encourage you to read the language very carefully. There are some nuances buried in the language that would influence certain decisions that you make when treating these patients. And then just, you know, my personal feeling about guidelines, I think it's completely fine to disagree at times. So the guidelines are not meant to be mandates that you have to follow in every single situation. They are what they are described to be, and that is just a guideline. So again, as far as what we're going to really focus on today, what's new and different if we compare the 2023 guidelines to the 2014, and I'm going to focus on those recommendations that are going to have the most impact on actual day-to-day clinical practice. I'm going to focus on some of the studies that drove the major changes or additions to the guidelines. And you'll notice on some of the slides that I have some red stars and I have some yellow or orange stars. The guidelines that I don't necessarily completely agree with are going to get these red stars, and then the ones that are really just common sense will get these orange ones. And also, if you have any questions as I'm going through this, please go ahead and speak up and we can stop and go into more detail. All right, so let's just go over the biggest take-home points. So they've proposed a new atrial fibrillation classification scheme. So it's a move away from describing AFib just based on duration of arrhythmia. And there's more of a focus now on stages of atrial fibrillation, which I think is really great because we all know now that this is a disease that has a continuum. So you can transition from one type of AFib to a different type of AFib, and then you can actually transition back. So I think this is a great addition that they've made. There is a lot more focus on risk factors, on prevention of atrial fibrillation, and also preventing progression. And here in bold, I've made a point that they focus on trying to be multidisciplinary and having a very cohesive treatment approach. Now, you know, if you look here at the dates, this is an article that we published in EP Lab Digest back in 2021, really explaining why a comprehensive atrial fibrillation program makes a lot of sense and benefits patients in the long run. So guidelines are a little bit behind the times because a lot of us, we've been doing this for several years now, but I am glad that they are focusing on it now as opposed to not focusing on it at all. So some of the new class one indications, and I'll talk about these in more detail as we move along here. One really big one, catheter ablation is now considered a first-line therapy in select patients. Another really, really big one that has been, you know, part of our practice for several years now, catheter ablation in patients with atrial fibrillation and systolic dysfunction. A few other really big ones, left atrial appendage occlusion now has a class 2A recommendation. It used to be a 2B, so that's been bumped up to a 2A now. And another really big one is using a consumer wearable. So an Apple Watch, Cartier mobile device, this now has a class 2A recommendation, which means we have a lot of good clinical evidence that these devices are not only reliable to patients, but extremely useful in terms of guiding management and helping the patients make decisions about what the next best steps are. There is a much stronger emphasis on early rhythm control. When I'm talking to people in the office, I describe this as being more proactive versus reactive. So again, if you go back to 2014, those guidelines, we tended to be a lot more reactive versus proactive. So I think this is a very good step in the right direction. And then there are updated recommendations for subclinical atrial fibrillation, which means you are detecting it not based on symptoms or on 12 EKGs. You're detecting this type of a-fib using devices. And I think this gives us a lot of ground to stand on because there were a lot of questions and gray zones when it came to a-fib that was diagnosed this way. All right, so let's start with the classification detection prevention piece of these updated guidelines. So previously, as I said a few slides ago, it was all based on duration. So paroxysmal means that the arrhythmia has been ongoing for less than seven days. The patients have not required a cardioversion. Persistent means duration greater than seven days or a cardioversion was performed. And then long-standing persistent is greater than 12 months in duration. A permanent essentially means that all rhythm control measures have been abandoned and atrial fibrillation is going to be that individual's baseline rhythm moving forward. So here's the new proposal. You can see a very big change. We have stages now. So stage one means that somebody is at risk for developing atrial fibrillation. And if you look at these modifiable risk factors, it's going to be the stuff that you all know about already. Obesity, sedentary lifestyle, hypertension, sleep apnea, heavy alcohol use, diabetes, to some degree genetics, being male and being older. Then we move on to stage two. So this is someone that is more likely than this group to develop atrial fibrillation, but has not yet. So someone who has left atrial enlargement on an echo or someone who has a lot of PACs or an EKG that you do in the office. Somebody that you've found to be an atrial flutter previously. Other high-risk AFib scenarios, post-surgery, someone that has some type of atrial arrhythmia in the hospital. And then if you move into stage three, these are various different forms of true clinical atrial fibrillation. Paroxysmal would be stage three. Persistent stage 3B. I'm sorry, paroxysmal stage 3A, 3B is persistent. Long-standing persistent would be stage 3C. And curiously, I'm not sure why they did this, but somebody that's had a successful ablation with a good outcome, they are now stage 3D, which I think is a little bit unusual because, again, if you think about cancer staging, the higher the letter, the worse the situation. I would argue that somebody that is doing very, very well following an AFib ablation should not be considered to have a more advanced form of the disease. And then permanent AFib is stage four. As I just mentioned, this would be somebody, we're not really going to pursue any more rhythm control measures. And very important to understand, especially in the stage three group, people can move back and forth, right? So you could transition from stage 3A to stage 3C if we don't intervene. And you could, in a way, move from stage 3D to stage 3A. Okay, so this is more of an active continuum. Regardless of what stage you're in, we want to address the modifiable risk factors, which we'll go over. As far as monitoring is concerned, once you get to stage two, you want to consider maybe having them get a Cardi mobile device or purchase an Apple Watch, keep an eye on things. And then once you get into the true clinical AFib, you want to monitor them as you think is appropriate. There's really no hard and fast rule here. Regardless of what's going on with the type of AFib, you want to make sure that they are not developing other problems that could be related to the arrhythmia. So this is the, for instance, the tachycardia-mediated cardiomyopathy group or the post-conversion pauses group. You should always be looking at stroke risk and trying to minimize that risk as much as you can and treating symptoms. This is something that would be pertinent regardless of what stage you're in. Okay, so I think a very, very useful new way of thinking about this. The only curiosity is this stage 3D. I think that's a little bit backwards there. Okay, so as far as detecting the arrhythmia, so a new class 2A recommendation, if you have somebody who has atrial fibrillation and you think it makes a lot of sense to monitor them. So this would be somebody who has very early stage atrial fibrillation, paroxysmal, episodes are brief, episodes are infrequent. This is someone that you may not necessarily be thinking about putting on a drug or taking to the EP lab for an ablation. They really should be keeping an eye on what's going on in terms of duration. And in these people, this new recommendation is it's reasonable to recommend a consumer device. So again, Cardi Mobile, an Apple Watch. So this is the guidelines really catching up with something that has been going on in the real world for a number of years now. It's still not clear if there is any significant benefits screening people based on these different scoring systems that can predict whether somebody is going to develop atrial fibrillation. So that's still a bit of a question mark. I would say very few of us utilize any of these risk scores to figure out if somebody is going to develop AFib in the future. OK, so again, a very, very strong emphasis on looking at risk factors. OK, so so class one recommendation, anybody that's at risk for atrial fibrillation, and I would extend this to somebody that already has been diagnosed with the arrhythmia, try to address as many of these modifiable lifestyle factors as you can. So obesity, being sedentary, heavy alcohol use, smoking, diabetes, hypertension. So the stuff that you all know about already. So somebody that's overweight, they picked a BMI of 27, and that's why I put these red stars here, because I think I'm not sure it's very useful to pick this arbitrary number. What I would say is anybody that is not considered to be normal weight, they should try to get as close to normal weight as possible. There are a bunch of trials and studies that suggest if they can if they can lose at least 10 percent of their baseline weight, they should see a reduction in the severity of symptoms related to a fib. The burden tends to go down. It reduces the likelihood of recurrent events, and then it also minimizes the risk that they will progress to a more persistent form of atrial fibrillation. So so weight loss now has a class one recommendation in these new guidelines. OK, another class one recommendation that's new, if you have atrial fibrillation, you really should try to exercise. I gave this one three red stars also because they picked this, again, very arbitrary 210 minutes per week of moderate to vigorous physical exercise. And again, in the real world, nobody is going to sit in an exam room and tell somebody you should be exercising 210 minutes per week. I would say exercise as much as you can, given whatever time restraints you have. And this would not apply to somebody that really thinks that they go into atrial fibrillation because of exercise. Or if we think that they have these atrial arrhythmias because they are exercising too much. So this would be the ultra endurance athletes, some of the cyclists that do a lot of miles a week. They probably develop an atrial myopathy from the exercise. And so if that is suspected, you probably want to tell them to do a little bit less versus more. But that at the end of the day is going to be a pretty small group. OK, so here you can see a bunch of orange stars because these are all, I think, important to put in the guidelines, but they're very common sense. If you have if you have AFib, you shouldn't be smoking. You should avoid or minimize alcohol consumption. Certainly not anything more than what would be considered in moderation. And then we should try to keep blood pressure optimized in those people that have underlying hypertension. So we all know that we should do this. This should be done for reasons beyond having arrhythmias. So important to have in the guidelines, but really more common sense than anything else. OK, this is a this is a big one, I think, because for a long time we were heavily restricting patients when it came to certain things and caffeine was one of them. So this is now a class three recommendation, which means you should not do it. You should not recommend that people abstain from caffeine altogether because there is no evidence that it's of benefit. There are people that are there are patients who are going to tell you that they really think that caffeine is a trigger for them. And in those cases, you should tell them, well, if you think it's a trigger, then yes, try to reduce or eliminate your caffeine intake. But for the for the entirety of people that have these atrial arrhythmias, there's no evidence. And, you know, again, from a lifestyle point of view, a lot of people really do enjoy drinking coffee and there's no good evidence to suggest that they need to stop. So I think this actually is a pretty big one. Sleep apnea. So this one you can see I gave this one three stars. This dropped down to a class to be recommendation. And this is pertaining to screening for sleep apnea and people that have atrial fibrillation. And the reason they gave it a 2B is the evidence is a little bit contradictory. So if you look at observational studies, there is some suggestion that it's useful in randomized, randomized control trials. The evidence is not as convincing, but the studies have been underpowered. So the way I look at this, sleep apnea, again, is is bad for many different reasons. Not just because of increased risk of arrhythmias. So I think if you have someone that you suspect has significant sleep apnea, they should be screened for it regardless. The only thing this is saying is how much of an impact it really has on on atrial fibrillation and other atrial arrhythmias is a little bit uncertain right now. But I still think if you think this may be a problem for someone, it's certainly worthwhile to screen them for it. And this now is more about the comprehensive care piece. So this is now a class one recommendation, which obviously it should have been for a long time. But we should utilize a comprehensive and multidisciplinary approach, focus on the risk factors, assess the symptoms, and then look at what somebody's stroke risk. And you have to remember, stroke risk, again, is a very dynamic thing. So somebody may, when you start taking care of a patient, they may be at a very low stroke risk. But over time, that degree of risk can and most likely will change. That should be something that several people are looking into on an ongoing basis. And then a class two recommendation is using clinical care pathways. So this would be something like a nurse or an APP-led atrial fibrillation clinic, which we do have at Piedmont Heart. And they say this is very reasonable to improve overall management, which again, most of us in the field agree this is certainly true. All right, so now transitioning to a separate portion of the guidelines, and this is preventing thromboembolism or preventing stroke. Okay, so the class one recommendations, assessing annual stroke risk, and again, the CHADS-VASc 2 score is still the most validated. So that's the one that is recommended to be utilized. But you have to remember, you need to look at what the bleeding risk as well. So evidence of prior bleeding, especially major bleeding. The need to use other drugs that may increase bleeding risk. So antiplatelet therapy, for instance. And then looking at somebody's fall risk, gait instability, all of those things. These need to be taken into account also when you're trying to figure out what the most appropriate strategy is for reducing the risk of stroke. A class two recommendation. If you have somebody that is intermediate in terms of risk, and the individual is a little bit uncertain about using an oral anticoagulant, very, very important that you discuss other factors that might influence stroke risk that are not represented by the CHADS-VASc score. So this would be, for instance, left atrial size. So someone who is intermediate based on the CHADS-VASc score, but has severe left atrial enlargement, they would be at increased risk that's not really reflected in the score. And then also the type and burden of atrial fibrillation. So if you really think about it, CHADS-VASc score does not take into account whether somebody is paroxysmal or persistent. And this certainly does play a role, and the patients need to be counseled about that. Another one that's not listed here would be hypertrophic cardiomyopathy. We know that regardless of the type of AFib that they have, their risk is increased. The CHADS-VASc score does actually not even apply here. They should be put on oral anticoagulant unless there's a very strong contraindication. So class three recommendations. Do not use a bleeding risk score in isolation to figure out if you should anticoagulate someone. So this is, at the end of the day, going to be a risk-benefit discussion. So if you would consider an individual to be at increased risk of bleeding, you also need to really look at what the true or estimated stroke risk is. And even if the bleeding risk score is on the higher side, the stroke risk outweighs that, then you should probably favor putting them on an anticoagulant, or as you'll see in a few slides, considering left atrial appendage closure. And the reason for this is there is too much overlap between the bleeding risk scores and the stroke risk scores. So they share different variables in common. So you really have to look at them independently, have the risk-benefit discussion with the patient, and then proceed accordingly. All right, so going back to a new class one recommendation, you should anticoagulate based on the stroke risk, not based on the atrial fibrillation pattern. Needs to be taken into account, but ultimately the CHA2S2-VASc score is gonna trump anything else. The way that I interpret this is in somebody that's paroxysmal, we should not be tempted to not anticoagulate them just because they're paroxysmal. On the other hand, somebody who has a low CHA2S2-VASc score, so you would then say stroke risk is low, if that person tends to have much longer duration atrial fibrillation events, or is quasi-persistent, I think that warrants a discussion. So it's really more so on the paroxysmal side. So don't avoid anticoagulation just because they are paroxysmal. And then also part of the class one recommendations, reassess what you should be doing to reduce their risk of stroke and what strategy you wanna utilize at periodic intervals, I would say at least every six months, at the longest, every 12 months. So if you recall from the focused update in 2019, the inflection point as far as deciding to anticoagulate was modified because female gender was one of the aspects of the CHA2S2-VASc score. So now a new class two recommendation, if you're on this lower end of the stroke risk spectrum, which would be a score of one in males and a score of two in females, which means the risk is between one and 2%, anticoagulation is reasonable. And this again would just come down to having a conversation with the person that you're taking care of. So you don't have to technically based on the guidelines, but it's very reasonable. And again, you have to take those other factors into account that I had just mentioned a few slides ago. Okay, so another very, very important one, class three recommendation, which means do not do, it's associated with either harm or no benefit. Do not use antiplatelet agents, meaning either aspirin or clopidogrel or a combination of the two, instead of using a true oral anticoagulants. Okay, so if you think about it, we now know that the nidus, most of these thrombi and atrial fibrillation arise from the left atrial appendage, which is typically a large structure, right? Antiplatelet drugs are very effective at preventing thromboemboli in smaller vascular beds. So coronary arteries, intracerebral vessels, not very useful at preventing larger thrombus, such as you would expect within the appendage. So this idea of using aspirin or clopidogrel instead of an anticoagulant, this is a concept that we no longer ascribe to. Firstly, because it doesn't really protect them. And secondly, it does increase the risk of significant intracerebral bleeding. So if you've got someone on the lower end of the stroke risk spectrum, do not resort to using aspirin anymore. That's no longer something that is recommended. And again, in individuals with atrial fibrillation and no significant risk factors for stroke, aspirin is of no benefit, but may actually come with significant risk. So this, I think, is a very, very big one. And you'll notice as you keep seeing patients, you'll see a lot of people who are on aspirin for AFib and they should not be on aspirin anymore. That's right, I forgot that I put stars for the really important things. So this slide, I think, is very important. And we will probably, at Piedmont Heart, we'll be using this as one of our quality metrics. So looking at people who have atrial fibrillation who are not really candidates for oral anticoagulation, how many of them are on aspirin? Our goal, obviously, would be to get to zero. Okay. Okay, a big one, very big one that has, I think, plagued a lot of people for a long time. What do you do with people who have some sort of implanted device and you start picking up episodes of AFib? What do you do in that setting? So this is a new class two recommendation. So based on very strong, compelling evidence. If you have a CHA2DS2-VASc score greater than two, and we detect any atrial high rate episode, so that's what this acronym means, atrial high rate episode. So this would include atrial fibrillation, focal atrial tachycardia, atrial flutter. If it's more than 25 hours in duration and your stroke risk is increased, it's reasonable to anticoagulate. I would probably take it a step further and say, you absolutely should anticoagulate them unless they personally do not want to do that, or if you have a compelling reason not to do it. Okay, another very important one. So longer than 24 hours, I think this is, this should be pretty clear-cut anticoagulate unless you have a compelling reason not to do so. Okay, class 2B. So the evidence is not quite as strong, but it's still strong enough to be recommended. Anything between five minutes and 24 hours, and your stroke risk is a little bit higher, so this is now CHAZ-VASc of three, still reasonable to anticoagulate. And this, again, comes down to an in-depth discussion that you have to have with someone. And for me personally, once I've seen any episode that's more than six or eight hours in duration, that means at any point in the future, this person could have a very prolonged episode, and then would be at risk. And given how low the major bleeding episode rates are with the direct oral anticoagulants, I think you offer that to them unless they really, really are opposed to it. Okay, so another, I think, very, very important slide. Gives us a lot more clarity than we used to have. Class 3 recommendation, which also I gave a star to, very important. If you have episodes that are less than five minutes in duration, so these are, you know, all of these people that have pacemakers or defibrillators, and they have, or loop recorders, and they do have AFib, but the episodes are 10 seconds, 45 seconds in duration, something along those lines. There is no evidence that they benefit from being anticoagulated. And again, the more days on an oral anticoagulant, the higher the risk of bleeding. So this is probably the most important one of the last three. This gives us a very specific cutoff in terms of duration. Nothing longer than five minutes. You really should not put them on an anticoagulant. So what's this based on? This is based on a few different trials. So the NOAA trial was published in September, 2023. So this is a doxaban versus a placebo versus nothing for atrial high rate episodes and people that had pacemakers or ICDs. In this study, the median duration was just about three hours. And the people that were randomized to receive a doxaban had increased bleeding, and there was really no benefit in terms of reducing stroke risk. But if you look down here at the bottom, the stroke risk was very low in both of these groups, right? 0.9% for the doxaban group, 1.1% for placebo. So overall, the stroke risks were very low, which is why you wouldn't really expect to see a whole lot of benefit here in this type of population. Artesia was published this year in January. So this was a pexaban versus 81 milligrams aspirin. And these were the people in that sort of grayish zone where anticoagulation would be considered reasonable. So anything between six minutes to 24 hours. So pexaban did reduce the risk of stroke or thromboembolic events to other parts of the body. And this was significant statistically, although if you again look at the overall percentages, still very, very low for both groups. And the pexaban did increase the risk of major bleeding. But same story, significant statistically, but in real life, a lot of us don't feel that this is probably very meaningful, right? It's 1.5% versus 1.1%. So for this particular group of people, I would say based on Artesia especially, it's still very much in the gray zone. You just have to talk to the individual that you're taking care of. Yeah, so again, in that group, between five minutes and 24 hours, we still don't really know what to do. You just have to utilize clinical judgment and have a really good in-depth discussion about the pros and the cons with the person you're taking care of. Okay, another big one that has changed now, closing the appendage. So this is now a class 2A upgraded from a class 2B based on a number of different studies. So this would be somebody that, is at increased risk of stroke, but has a true contraindication to long-term anticoagulation because of something that is not reversible. So a good example would be a GI bleeder who probably has an AV malformation that can just not be treated, right? So that's not reversible, and they suffer major bleeding when they get anticoagulation. That type of person closing the appendage percutaneously is now considered to be reasonable with the understanding that it's an invasive procedure and there is potential risk. Class 2B, I think another big deal that they added this, same type of individual, but now we can say that left atrial appendage occlusion is reasonable if that's what the patient prefers. And again, we need to counsel them extensively about the procedural risk, and also make them aware of the fact that we have a lot more and longer standing evidence for oral anticoagulation than we do for appendage occlusion at the moment. But you can offer this to them if it is their strong preference and they have been counseled that we don't have as much data if you compare it to using an oral anticoagulant. So this, I think, is a big one. And we have some studies that have not yet been published, but will probably be published in the near future. And those two trials are the Catalyst at the bottom left. This is using the Amulet device, and then Champion, which is utilizing the Watchman Flex device. And both of these trials were really enrolling people that were not terribly high risk for major bleeding. And it was really driven by patient preference. So Catalyst and Champion could potentially change this class to be recommendation depending on what the outcomes look like. So everybody is watching this very, very carefully. Okay, so this, I think, another big slide because it's a significant departure from the previous guidelines. So closing the appendage surgically, it's a class one recommendation. If they are undergoing cardiac surgery for a different reason, and they are high stroke risk, then it's recommended to close the appendage with ongoing oral anticoagulation. And what they don't say in the guidelines, but I'll add here is with ongoing oral anticoagulation so we can assess the degree of success of appendage closure, right? So this would be a TE or a CT scan, just to make sure that the appendage is truly adequately occluded, and you don't have any residual appendage or pectinate muscles that could provide crevices for thrombus formation. And then again, part of the class one recommendation is you just have to use some sort of technique that results in no flow across the suture line, and you have a stump that's less than one centimeter in depth. Okay, class two B, same exact story, but this is performing the operation and then stopping the oral anticoagulant altogether. We don't know what the benefit of that is, and that's largely because imaging the appendage post-surgery is not really something that's been standardized up to this point. So we don't know if this is really of benefit or not. Okay, another big one that we're gonna come across more and more, so someone that has atrial fibrillation and coronary disease. So class one recommendation here, if they have AFib with high stroke risk and they are ongoing PCI, certainly DOACs are preferred over Warfarin in combination with antiplatelet therapy. So a lot of clinical trial data suggesting absolutely use a DOAC if you can versus Warfarin if you're gonna put them on antiplatelets. And then people with AFib who are already on an oral anticoagulant and are now undergoing PCI, trying to discontinue aspirin and then continuing the anticoagulant plus a PTY-12 inhibitor is preferred over triple therapy. So again, that 30-day mark to get rid of one of the antiplatelets is preferred versus keeping them on all three drugs for an extended period of time. Okay, if you have AFib and you have chronic coronary disease, so you're more than one year out from some sort of revascularization or you have coronary disease that did not require an intervention, and it's important, and you've never had prior stent thrombosis, using an oral anticoagulant by itself is recommended over using an anticoagulant plus a single antiplatelet agent. And this also is a class one, so based on very, very strong evidence. So once you get to a year and you've not had a stent thrombosis, it's completely fine to be on a DOAC by itself versus a DOAC plus aspirin, clopidogrel, et cetera. If you have peripheral arterial disease, this is a class two, so not quite as strong. And it's stable. Again, oral anticoagulation as monotherapy is reasonable versus anticoagulation plus an antiplatelet. Okay, a few things about rate control, and I'll go through these a little bit quickly because this is not necessarily very new information. Class one, in almost everybody, I think you really should discuss rate versus rhythm control strategies and then give them the pros and the cons. Again, 20 years, and this is what I tell a lot of patients, 20 years ago, there was a lot of focus on symptoms, right? So if you were very symptomatic, then you got a rhythm control approach. And if you were quote unquote asymptomatic, the focus was on rate control. We now know that atrial fibrillation is a very, very bad arrhythmia in the longterm, regardless of how it makes you feel. So even the people who say that they have no symptoms, you need to make them aware that there are longterm negative consequences if they progress to persistent a-fib, and you have to give them the pros and the cons, rhythm versus rate control. So class 2a, if you have a-fib and you don't have any clinical heart failure, then number one, the heart rate target is really gonna be guided by symptoms. But in general, you wanna be somewhere between 100, 110 beats per minute, and that's the average. So a little bit higher with exercise, a little bit lower during sleep and sedentary activities. Another class one, if you have a-fib with rapid rates, but you're otherwise clinically stable, you can utilize beta blockers, or you could use non-dihydropyridine calcium channel blockers, assuming that you don't have severe LV systolic dysfunction. Class 2a recommendation, if you have a-fib with rapid rates, but for whatever reason, the patient cannot tolerate calcium or beta blockers, calcium channel or beta blockers, you can think about digoxin, obviously something that in the hospital, especially, we do all the time. This is an interesting one. I don't know if I've really experienced this myself in reality, but it is a class 2a recommendation based on a bunch of different studies. So a-fib with rapid rates, apparently adding IV magnesium is reasonable. So it may have an impact on calcium channels, which might make it easier to control ventricular rates. Again, not something that I've really seen myself, but there is enough evidence for the Guideline Committee to have given it a 2a recommendation. So class 2b, someone that has rapid rates and has decompensated heart failure or some other critical illness, and you really don't wanna use any drugs that could remove inotropy or make them potentially hypertensive, you can use intravenous amiodarone for acute rate control. And again, the risk here, theoretical risk would be that you cardiovert somebody pharmacologically who has not been anticoagulated. In real life, the likelihood of that happening, I would say, is extremely low. So it's a potential risk that you have to take into consideration, but unlikely that it's actually going to happen. And amiodarone does have a lot of beta blocker properties. So from a rate control perspective, it can be very, very useful. So here's another big one that I think all of you already know about. And this is sometimes a bit of an issue somebody is presenting to the emergency room and we don't know a lot about them. They come into the emergency room with rapid atrial fibrillation. We don't know if they have a low ejection fracture or not. Intravenous diltiazem in somebody like this could be catastrophic or even fatal. So using intravenous non-dehydropyridine calcium channel blockers should really be avoided if you know that they have a low ejection fraction. And I would also add, if you don't really know anything about what their ejection fraction might be, can be a very dangerous situation. Same situation here on this slide. Ejection fraction less than 40%. They say you shouldn't use calcium channel blockers. I think this is a case-by-case decision that you have to make. If somebody is acutely decompensated, probably not the best idea. Somebody that is not acutely decompensated, I think you can't think about it if you've already maxed out other drugs. And then dronetarone, a class three recommendation. Somebody that has permanent AFib and has other risk factors for cardiovascular events, dronetarone should not be used for rate control. This is really based on just one trial, but the data was pretty compelling, so I think this is reasonable. A class one recommendation, this is something that has been around for a while, but some of you may not be aware of this. If we do an AV node ablation on someone who is either then undergoing pacemaker or ICD implant or already has a device, when you initially do that AV node ablation, we want to bump the lower rate limit to 80 or 90 beats per minute because this reduces the risk of sudden death, which would be more applicable in someone with a pacemaker than an ICD. But if you ablate the AV node and leave them with the typical lower rate limit of 60, there is actually an increased risk of arrhythmic death, of ventricular arrhythmic death. So at least for some ill-defined period of time, we want the heart rates to be 80 to 90 to reduce that risk. AV node ablation, again, this is a class two recommendation, can be useful to improve symptoms and quality of life. Again, in clinical practice, a lot of a lot of experience with this and people actually tend to do very, very well. So 2A is a strong recommendation, but I think in real life, a lot of people probably say in a lot of individuals, this should be a class one. Class 2B, so this is new for us, conduction system pacing, these days is a lot of interest in left bundle branch area pacing specifically. So in someone that has AFib, a normal LVF, and you are doing an AV node ablation, you really should, can and should consider conduction system pacing upfront. They will be a lot less likely to develop a pacing-induced cardiomyopathy if you employ conduction system pacing. So again, these days, most commonly, it's going to be left bundle branch area pacing, but there are still a few of us out there who do his bundle pacing as well. Okay, so switching now, this is probably the most pertinent part of what we're going to talk about, and that is new updates to the guidelines pertaining to rhythm control. So class one recommendation, if you have a lot of AFib and you have a low ejection fraction, at least a trial of rhythm control is recommended to see if the AFib is contributing to the systolic dysfunction. So this would be anybody that you think could possibly have a tachycardia-induced cardiomyopathy. They really deserve at least some attempts at rhythm control, and then you see what happens with the ejection fraction. And the outcomes data from trials is compelling enough for this to now be a class one. Class 2A, anybody with symptoms, rhythm control may be useful to improve symptoms. And again, the problem with this concept is the symptoms sometimes can be so subtle that people don't really understand that they were symptomatic until we reduce the AFib burden. So again, the people that are asymptomatic, I personally always take that with a grain of salt, and we have another discussion once we've achieved a reasonable degree of rhythm control, and they tell me if they were really asymptomatic or not. So especially in recently diagnosed AFib, so less than one year, and this is again based on a very, very large international trial called the EAST-AFNet4, rhythm control is useful to reduce very hard endpoints, hospitalization, stroke, and even mortality. And if you remember when I first started the talk, I said, you know, today, contemporary thinking is let's be proactive versus reactive, and this is really what I was referring to. So the earlier we can initiate rhythm control, the better people tend to do it, not just in terms of quality of life, but in terms of ending up in the hospital, having a stroke, and living longer. Okay, so this is another very, very big slide. It's a significant departure from how we used to think about atrial fibrillation, especially in the early 2000s. Okay, so this trial is important enough just for me to give you a few details. So 2,700 patients approximately, so a big number. They all had recently diagnosed AFib. They were randomized to either rhythm versus rate control. Rhythm control resulted in a large reduction in the composite endpoint, which included mortality, stroke, and hospitalization for cardiovascular causes. So very, very significant reduction in that endpoint with early rhythm control. If you have heart failure, this is certainly also true, and this is, again, driven by data from East AFNet, and then also by CABANA, which was another big international trial. And if you look at CABANA, specifically focusing on the subset of people that had clinical heart failure, a 46% reduction in mortality if these people underwent an ablative strategy versus drug therapy. I'll get back to that in a second here. Okay, important slide. So in heart failure, rhythm control is probably even more useful and beneficial than in people that don't have clinical heart failure, and we're starting to now see a lot of data suggesting that ablation is going to be superior to using antiarrhythmic drugs. Another class 2A, rhythm control may be useful to reduce the progression of AFib. And I'll just make the point here, it's not in any of my slides, but we've now realized that you don't have to get somebody to 0% AFib burden for them to experience a lot of benefit. So if you can reduce somebody's burden to 1% or less, they basically will get the same clinical benefit as somebody that does not have atrial fibrillation whatsoever. So this idea that we have to cure somebody's AFib is outdated. We just need to dramatically reduce burden. So 0% is not necessary. What we now are really aiming for is 1% or less. Okay, and we can utilize drugs and or ablation so that somebody remains paroxysmal for the foreseeable future versus progressing to persistent or longstanding persistent. And again, here, this is what I was talking about a few slides ago, this is a class 2B. Correlating atrial fibrillation and symptoms is a little bit tricky. And so if someone is not really certain or convinced that they are actually symptomatic, a brief trial of rhythm control, which would typically mean using a drug, may be useful so that you can actually figure out if they have symptoms or not. Another class 2B, which is new based on more contemporary data, and I was thinking about AFib, controlling rhythm may be useful to reduce the likelihood of developing dementia and worsening structural heart disease. So we now know, if I'm taking somebody to the EP lab who's been in AFib for five years, I'm already expecting that they will have a pretty significant atrial myopathy, a lot of fibrosis. Those people, even if we put them back into the sinus rhythm again, they don't have a whole lot of atrial systole because the atria have gotten so diseased already. And then the dementia part of this, it turns out that the small arterial vessels in the brain are really not equipped to deal with the fluctuations in pulsatility that we see with atrial fibrillation. So even if you protect them from stroke, they are still much more likely to develop cognitive impairment and that's related to this irregularity in terms of how the blood vessels in the brain are experiencing that pulsatility delta. So something that I think we really need to start emphasizing to patients is AFib is not going to kill you, but it is going to significantly increase the risk of you developing clinically meaningful dementia or cognitive impairment. All right. The class 3s as far as the antiarrhythmics, and I think most of you already know this, previous myocardial infarction or any significant structural heart disease, we don't want to use the class 1c drugs, so fleconide and propafenone, and this is based on the COST trial, which was done again about 20 years ago. Another class 3 recommendation, dronetarone, which I think is a drug that is not used very frequently to begin with, but definitely avoid in class 3 or class 4 heart failure. Also avoid in somebody that is not quite as advanced, but has been decompensated in the past four weeks. In these two groups of people, dronetarone increases mortality. All right, I know we're almost at 8 o'clock, so I'm going to try to go a little bit quick. Antiretroviral ablation, again, probably the most relevant of the new guidelines here. It's now a class 1 recommendation for somebody who has symptomatic AFib and who has either failed a drug, cannot take a drug, or does not want to take a drug, so this is very important. If somebody prefers not to take an antiarrhythmia drug, ablation is very useful to improve symptoms. And then in selected patients with symptomatic and paroxysmal AFib, because it's important, they have to be paroxysmal, ablation is useful as a first-line therapy. So you do not have to start with a drug in somebody like this. You can proceed directly to ablation to both improve symptoms and reduce the risk of progression. So this, I would say, is extremely important. This is very different than in 2014. Same story for atrial flutter, if they are symptomatic or if the atrial flutter is significant clinically, for some reason, ablation is useful. Class 2a is not quite as strong of a recommendation, but in everybody. So even people that don't fall into that select category, which would be younger, very symptomatic, in anybody, if they have symptomatic paroxysmal or persistent AFib, ablation as a first-line approach can be useful to improve symptoms. Even in someone that has persistent AFib, we no longer need them to fail or not tolerate a drug before we discuss ablation with them. This can be discussed as a first-line option. Again, big departure from guidelines that were published in 2014. This is what I was also discussing before. In some people, generally when they say this, they mean people that are very good candidates for ablation, who have AFib and have either no or minimal symptoms. You can still discuss ablation with them because we know that it reduces the risk of progression and reduces the risk of developing downstream complications that could be related to atrial fibrillation, like cognitive impairment or other cardiovascular problems. Another class one that's new, if you have AFib that recurs post-ablation, either another procedure or adding an antiarrhythmic drug is useful to improve the symptoms and reduce the burden. And this is something that a lot of us do pretty routinely. If you take somebody for an ablation, it's very reasonable to put them on an antiarrhythmic drug in the short-term. Again, for us, 12 weeks is typically what we refer to as the blanking period. So especially in someone that's persistent, a lot of us will add an antiarrhythmic drug for three months post-ablation. And then depending on how things look during the procedure, we would either get rid of the drug or consider transitioning them to a different medication with less risk. Again, going back to somebody who's undergoing cardiac surgery, doing a surgical ablation can be useful to reduce the risk of recurrent AFib if somebody has a known diagnosis and is undergoing surgery for a different reason. And then again, these people really should be on an oral anticoagulant for at least three months post-surgery. And I would say this applies whether the appendage was ligated or not. So this should be the last segment. What do we do with people that have atrial fibrillation and heart failure? So this is a new class one recommendation. If you have a new diagnosis of AFib and your ejection fraction is depressed, strongly suspect an arrhythmia-induced cardiomyopathy. And then these people, we should pursue early and aggressive rhythm control because they tend to do extremely well. So the ventricles tend to bounce back very robustly if we get them back into sinus rhythm quickly. So in somebody that has AFib and a low ejection fraction, and they have been on guideline-directed medical therapy, if you suspect that they would have a good outcome, catheter ablation is beneficial to improve symptoms, to improve quality of life, potentially improve ventricular function, and reduce the risk of negative cardiovascular outcomes. This is a very important one. It's based... This slide is very busy, I know, but here is an example of all of the randomized trials that have been published in the last 10 to 15 years looking at the impact of rhythm control in people who have clinical heart failure. And overwhelmingly, all of these studies suggest that there is strong benefit with rhythm control, and more specifically, a very strong benefit with catheter ablation. This is also true for people that have a diastolic dysfunction, so heart failure with preserved EF. Ablation is very appropriate if you expect that they are going to have a good outcome. And this is mostly about symptoms and quality of life, less so about mortality and hospitalization rates. Athletes, another unique group, athletes who develop AFib, pulmonary vein isolation is reasonable for rhythm control. And mostly, this is because we know that if we ablate these individuals, we're not going to really have a lot of impact on their ability to exercise versus putting them on a beta blocker, for instance. If you put a competitive athlete on a beta blocker, this will interfere with their ability to perform. But isolating pulmonary veins will have no impact on their athletic performance. All right, good. So that's the last slide. So I'll stop there and address any questions you guys have. So, Dr. Houzian, thank you so much for sharing all of these robust updates with us and going through all of these different scenarios that can affect our clinical practice. There were a couple questions that if folks want to hang on, I'm going to try to get to quickly and I'm also going to make one quick comment. There was a question in the chat about your slides. Again, this is going to be recorded and the link to the recorded session will be in the CBTeams section of the website. There is a subsection on webinars, so I'm 99% sure that that's where it's going to live. So if you're interested in revisiting this content, it'll be available for you. Dr. Houzian, when you were discussing subclinical AFib, a question came across, and I'm assuming this was in relation to subclinical AFib, if someone has subclinical AFib in a CHADS VASc of zero, what are your recommendations? So yeah, well, CHADS VASc of zero, again, there is no real evidence that you should anticoagulate that person, especially if the AFib is subclinical. Yeah, so no, in that person, no. And then we had another specific, we had a scenario question, if a patient has undergone CABG with left atrial appendage exclusion, and they're pretty close, they're only post-op day five and have new onset AFib with a duration anywhere from five minutes to 24 hours, and they have a CHADS VASc of three, would you anticoagulate that patient? Yeah, so in that person, I would say yes. And then at some point post-discharge, I think the appendage needs to be imaged. And most likely, once they, for the surgical patients, most of us would use that same 12-week timeframe. So you give them 12 weeks, that allows all of the post-surgical inflammation to settle down, and then some sort of monitoring would be reasonable as well. If this is completely new for them. And then I think if you don't pick up any AFib on that monitor, and you've demonstrated that the appendage is adequately ligated or occluded, then you wouldn't continue anticoagulation beyond that point. One last question that came across, is it necessary to have DC cardioversion during the rhythm restoration process in persistent long-term atrial fibrillation while awaiting catheter ablation? No, it's not necessary. What I do, and this is discussed nowhere in the guidelines, this is just me describing what I do personally. If I have somebody that's longstanding persistent, what I might do is get them on an antiarrhythmia drug. So usually it would be amiodarone to spare them an admission to the hospital. And then after an adequate period of amiodarone loading, I would cardiovert them and see how they do. So if it's somebody on the younger side, if they stay in sinus rhythm for a reasonable period of time on the amiodarone, then at that point, I would discuss either ablation alone or ablation plus using a different drug with them. But no, you don't have to cardiovert them necessarily before you make a decision like that. Fantastic. Thank you so much. I told you guys this was going to be robust, full of information and extremely applicable, and Dr. Housian definitely delivered. There's tons of comments thanking you, Dr. Housian, for your extremely well-organized presentation and going through all of these, again, these clinical scenarios that affect our practice for our patients with atrial fibrillation. Really quickly, I want to thank Olivia Hansen, who's the strategy associate for the CV team for all of her work behind the scenes. And also, in the audience tonight were CV team education committee members, Dr. Sarah Sloan and Dr. Carla Widener, who have done so much work past, present, and future for this format. And I just wanted to mention them and thank them. And then lastly, again, thank you to Dr. Michael Housian for this fantastic presentation, making time for us and supporting the ACC CV team. Thank you guys for being with us. And we look forward to another presentation coming up, again, quarterly. And we'll have those announcements out more than likely on the CV team section of the ACC website. Thank you guys so much for joining us. For Dr. Housian and the CV cardiovascular education committee, this is Christopher Walsh. And thank you again for being with us tonight. Y'all have a great night. All right. Thank you so much.

atrial fibrillation

cardiovascular providers

updated guidelines

Dr. Michael Hoosian

stage-based classification

risk factor modification

multidisciplinary approach

catheter ablation

consumer wearables

thromboembolism prevention

anticoagulation